February 4, 2019
In our first article, we introduced a need for the modernization of paramedicine in California across three key areas—Training, Treatment, and Transport. In our last article, we discussed Training and the important educational advancements needed to bring paramedics within the accepted training standards of similar medical professionals to improve patient outcomes and to advance the industry as a whole. We now look to discuss the important topic of Treatment.
In California, every day we see the impact of societal challenges, such as as homelessness, mental illness, opioid abuse, and infectious disease, to name a few. Political and health care bodies spend an inordinate amount of time and energy looking for innovative approaches to address these areas and reduce suffering in our communities. Paramedics have demonstrated the ability to address these issues, if permitted to fully utilize their skills and provide interventions tailored to community needs. We believe that two tangible solutions can be effectively deployed to help in this regard: the implementation of Community Paramedicine throughout the state of California and the use of paramedic vaccination campaigns.
Community Paramedicine in California
By: Shawn Percival, Community Paramedic
In California, our paramedics and prehospital systems function incredibly well in acute emergencies. The dial of a phone can summon paramedics within minutes, bringing important life-saving knowledge, interventions, and subsequent expedited access to specialty systems of care. However, this classic reactive “treat and transport” approach has not been an effective solution in the management of non-emergent patients facing complex issues. These non-emergent patients comprise a majority of the calls paramedics respond to in our 911 systems.
Paramedicine is now evolving to interact regularly with at-risk populations and better triage patients on 911 calls to improve outcomes, reduce hospitalizations, reduce cost and increase system efficiency in what is called Community Paramedicine (CP). CP is defined as EMS-based strategies that address local public health, health care and public safety needs through evolving problem-solving techniques, community partnerships, and advanced roles or scopes of practice.
In November 2014, the Office of Statewide Health Planning and Development (OSHPD) approved an application by the California EMS Authority to initialize a Health Workforce Pilot Project (HWPP) to test CP across our state. The programs have proven both safe and effective as shown by the extensive, independent analysis performed by the University of California, San Francisco (UCSF) and the California Health Care Foundation (CHCF).
Thirteen local CP programs within the pilot are currently addressing healthcare needs such as post-discharge follow-up, frequent EMS use, tuberculosis management, hospice patient management, and alternate destination strategies for patients requiring mental health and sobering centers. Across all of these programs, paramedics leverage the health and public safety skills already used by 911-paramedics on a daily basis and repurpose them, adding techniques such as outreach, navigation, advocacy, primary care and other preventive services.
UCSF’s comprehensive review is available for your analysis. However in the interest of brevity, we have selected key takeaways from that report. Since their inception, the programs have enrolled over 3,000 patients. In post-discharge pilots, patient safety was increased and the programs saw “all-cause” 30-day readmission rates drop in the vast majority of groups, at a cost savings of $1.4 million dollars. Frequent EMS-user pilots saw dramatic success by reducing 911 utilization through the networking of patients to primary care, food and housing resources, mental health services, and substance abuse programming, saving $582,000 on a cohort smaller than 50 patients. In directly observed tuberculosis management, paramedics were able to safely administer treatment with higher compliance than the traditional clinic-based treatment model, missing only 0.05% of treatments in comparison with historic rates of 7%. If these diverse CP programs were taken to scale across the state, the impact and savings would be staggering.
With such demonstrable success, we then look to understand why recent legislative attempts to formalize community paramedicine have been unsuccessful.
The most recent attempt, Assembly Bill 3115, was ultimately vetoed by Governor Jerry Brown, who noted general support for the initiative but major concern with the proposed oversight structure. AB3115 was introduced and supported by labor organizations who sought to control CP at the state level and restructure the EMS commission, thereby gaining labor seats on that body. That bill’s sponsors disregarded the local control structure of the successful pilots and overlooked the important perspective of pilot program leadership in their pursuit of self gain. Labor organizations must be included in the discussion of CP implementation, but their political agenda should not jeopardize the ability of paramedics to provide for the needs of our communities.
The CP pilot program, as a whole, has now served its intended purpose and is reaching its sunset. OSHPD and the CHCF have fortunately extended the pilot program for one more year, after the politically-induced failure of the last legislative attempt. The California Paramedic Foundation fundamentally supports Community Paramedicine in both theory and practice. We believe CP legislation must be modeled on the current pilot programs so that its growth is anchored by ongoing success; a success that is built on control under local EMS agencies and medical directors, accountability to the state EMS Authority, and reporting to the EMS Commission.
Paramedic Delivered Vaccination in California
By: Josh Krimston, Paramedic
Viruses are an ever-present threat to our society. Each year 5% to 20% of Americans will face influenza. This can result in around 200,000 hospitalizations, 80,000 deaths, $10.4 billion in direct medical care costs, and $16.3 billion in lost earnings—in just one flu season. In 2014, the Ebola virus epidemic terrified the world with a 70% mortality rate and secondary international infections. The reality is infectious viral diseases are a continuous threat that must be addressed with pragmatic and proven public health strategies.
Recently, San Diego faced its own epidemic with the 2017 Hepatitis A outbreak. That event saw 578 infections and 20 deaths. The San Diego outbreak was successfully wound down in part through the use of paramedics, who provided vaccinations for tough to reach populations in a larger effort by public health providers and administrators. This approach was a highly successful component of the effort which turned the tide in an epidemic which had been growing out of control with expanding rates of infection and a rising death toll. This event shows the benefit of paramedic-driven vaccination campaigns and demonstrates the importance of their early implementation.
The deadliness of a Hepatitis A outbreak was clearly seen in San Diego, and yet this virus only has a mortality rate of up to 2% in at-risk populations. Other viruses, such as the H7N9 Bird Flu, have mortality rates of 30% or greater and also pose risk of outbreak. The World Health Organization (WHO) recognizes several viruses, including the avian strain, as threats with pandemic potential. When viruses of this magnitude threaten the health of our community, whether seasonally or sporadically, an all-hands-on-deck approach must be available.
The value of paramedicine in vaccination campaigns lies with their ability to reach populations not always accessible to public health nurses and other providers. Often public health nurses require peace officer escorts to reach populations accessible to paramedics, however this escort can often cause individuals to flee reducing efficacy. In a University of Pittsburgh study, 90 paramedics were able to vaccinate over 2,000 individuals against seasonal influenza, 49% of whom had not received the vaccine in the prior year. That program’s organizers found paramedics operated with high success and saw zero adverse outcomes.
Despite the clear opportunity to improve our response to these public health crises, current California law does not allow for paramedics to administer vaccines unless state regulators provide emergency authorization. This lengthy process delays decisive action when time is of the essence. Even with emergency authorization paramedic campaigns are still burden with nursing oversight, when ironically, the standard protocol for out-of-hospital allergic reaction—the most concerning adverse event with vaccine administration—is to call paramedics.
Unfortunately, some organizations do not generally support the expansion of paramedic scope of practice to include vaccination. They often argue paramedics are unqualified to deliver this critical service. The reality of the situation is that administering intramuscular injections or intranasal sprays is a core skill of paramedics in their day-to-day work. The low risk of allergic reaction to a vaccine can be expertly handled by paramedics, who are often requested via 911 to handle the most severe forms of these incidents.
Public health is not a zero sum game, and paramedics have proven to be a valuable and safe component in a comprehensive approach for the management of highly-infectious and deadly viruses. This value must be recognized with pragmatic legislation via EMS stakeholders and policymakers.
The Modernization of Paramedic Treatment
The time has come to modernize the way California paramedics treat our communities. Community paramedicine presents a viable pathway to begin addressing patient vulnerabilities in our communities. Can we really allow labor politics and gamesmanship to sideline an otherwise effective and widely used approach like Community Paramedicine?
The value of paramedics in vaccination campaigns has been vividly demonstrated, as well as the nonsensical, outdated rules that currently hinder its broader adoption. Paramedic vaccinations are low-hanging fruit in the important battle against deadly diseases. Can we really overlook this ready solution, when viral outbreaks truly threaten lives?
The California Paramedic Foundation is calling on stakeholders and legislators to work together for the modernization of paramedic treatment in California EMS, through the passage of Community Paramedicine into state law and the expansion of the paramedic role in the provision of vaccines.
About the Authors:
Shawn Percival: Shawn is a certified Community Paramedic (CP-C) credentialed by the International Board for Specialty Certification (iBSC) and has previously attended the Community Paramedic Training Program at University of California, Los Angeles. As a community paramedic, Shawn works with the City of San Diego Resource Access Program (RAP) to reduce low-acuity, high-frequency callers. A large focus of his work is with military veterans, who have increased risk of substance addiction and homelessness. Shawn and his colleagues provide access to primary care, addiction specialists, housing support and family reconnection services to help these populations. As a Community Paramedic, Shawn is committed to research that steers public health policy. Recent research by the San Diego RAP Paramedics on the Spice epidemic helped form the 2016 San Diego City Ordinance banning all synthetic drugs.
Josh Krimston: With over 25 years of paramedic experience in both the private and public sectors, Josh Krimston has taken his field experience and leveraged it to develop programs that fuse paramedicine and prevention. As co-founder of the nonprofit group EPIC Medics, Krimston recognizes the inherently unique position paramedics are in to affect positive changes in injury and illness prevention. In 2017, during San Diego County’s deadly Hepatitis A epidemic, Krimston worked with Public health officials to implement a paramedic-led vaccination program in his southern San Diego district. Krimston has travelled extensively throughout the United states promoting the integration of EMS and prevention and has authored numerous related articles and text book entries.